Date: 15 March 2017
Category: Collaborative care
Collaborative care started life in the US and, until the CADET study, it hadn’t been comprehensively tested in the UK health system.
NICE (National Institute for Health and Care Excellence) were keen to see the evidence on this method of coordinating the therapeutic care of patients with depression, so they could decide what guidance to offer for its use.
We set out to test the value of collaborative care as an organisational strategy. The point of CADET was to examine what happens when you have a worker who glues the various disparate elements of a patient’s care together, while giving them some low-intensity therapeutic input. What we learned from CADET is that if you look after patients in a structured way, keep in contact with them and give them some basic mental health advice, you can achieve good results.
When we set up the CADET trial we delivered the collaborative care intervention using graduate mental health workers, as the role of the psychological wellbeing practitioner – the mainstay of the IAPT service – had not yet been developed. The staff were trained as case managers, with responsibility for maintaining phone contact with the patient, guiding the patient in self-help, managing their medication, and providing consultation liaison with primary care.
Crucially, these case managers were supervised by mental health professionals such as psychiatrists, psychologists, nurses and other mental health experts. Case managers acted as the conduit for that professional expertise, ensuring they gave high-quality mental health care advice.
The low-intensity self-help component of the CADET trial was in the form of behavioural activation: agreeing on action goals and monitoring how the patient got on. The results for the collaborative care intervention were good and behavioural activation was a key part of this approach to patient care.
When, later, we set up the COBRA trial, we were testing a much more intensive form of one-to-one behavioural activation, substantially different from the guided self-help used in CADET. COBRA tested the hypothesis that benefits comparable to CBT could be achieved by using therapists with less training.
The BA approach is based on the premise that you don’t need to change the way you are thinking or feeling directly, what’s important is changing what you are doing. It says ‘go and do, despite what you are feeling, and you will notice a link between what you do and your mood'. Using this ‘outside-in’ approach, a personalised programme of activities will, in turn, have a positive effect on mood.
We were delighted that we got such positive results from the COBRA trial. It gives us a definite indication that BA was not inferior to CBT and I am optimistic that NICE will now consider BA in their revised guidelines for people with depression.
Dave Richards, Professor of Mental Health Services Research, explains how the CADET study set about evaluating collaborative care.
Professor of Mental Health Services Research, University of Exeter